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psnet.ahrq.gov/node/42156/psn-pdf
April 03, 2013 - The effect of a checklist on the quality of post-
anaesthesia patient handover: a randomized controlled
trial.
April 3, 2013
Salzwedel C, Bartz H-J, Kühnelt I, et al. The effect of a checklist on the quality of post-anaesthesia patient
handover: a randomized controlled trial. Int J Qual Health Care. 2013;25(2):176…
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psnet.ahrq.gov/node/46264/psn-pdf
August 09, 2017 - Intraoperative handoffs among anesthesia providers
increase the incidence of documentation errors for
controlled drugs.
August 9, 2017
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the
Incidence of Documentation Errors for Controlled Drugs. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/44409/psn-pdf
January 22, 2016 - "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of questions
during end of shift handoffs.
January 22, 2016
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of question…
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psnet.ahrq.gov/node/866203/psn-pdf
June 26, 2024 - How a major public hospital is protecting doctors by
silencing the patients who accuse them.
June 26, 2024
Kamb L. NBC News. June 14, 2024,
https://psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse-
them
Transparency is a primary element of an organizational safety cu…
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psnet.ahrq.gov/node/47595/psn-pdf
March 06, 2019 - Approaches and Challenges to Electronically Matching
Patients' Records Across Providers.
March 6, 2019
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-
provid…
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psnet.ahrq.gov/node/43942/psn-pdf
March 11, 2015 - FDA requires label warnings to prohibit sharing of multi-
dose diabetes pen devices among patients.
March 11, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.
https://psnet.ahrq.gov/issue/fda-requires-label-warnings-prohibit-sharing-multi-dose-diabetes-pen-device…
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psnet.ahrq.gov/node/37770/psn-pdf
March 10, 2011 - Identifying and quantifying medication errors: evaluation
of rapidly discontinued medication orders submitted to a
computerized physician order entry system.
March 10, 2011
Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidly
discontinued medication orders su…
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psnet.ahrq.gov/node/846764/psn-pdf
March 29, 2023 - Senators threaten consequences after VA confirms 4
deaths tied to computer system tested in Spokane.
March 29, 2023
Donovan-Smith O. Spokesman Review. March 15, 2023.
https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-
system-tested-spokane
Implementations of elec…
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psnet.ahrq.gov/node/42362/psn-pdf
July 10, 2013 - How to improve change of shift handovers and
collaborative grounding and what role does the electronic
patient record system play? Results of a systematic
literature review.
July 10, 2013
Flemming D, Hübner U. How to improve change of shift handovers and collaborative grounding and what
role does the electronic p…
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psnet.ahrq.gov/node/41389/psn-pdf
June 27, 2012 - Can we make postoperative patient handovers safer? A
systematic review of the literature.
June 27, 2012
Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesth Analg. 2012;115(1):102-15.
doi:10.1213/ANE.0b013e318253af4b.
https:/…
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psnet.ahrq.gov/node/73296/psn-pdf
May 19, 2021 - AHRQ Safety Program for Methicillin-Resistant
Staphylococcus Aureus Prevention. Request for Proposal
Comment.
May 19, 2021
Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.
https://psnet.ahrq.gov/issue/ahrq-safety-program-methicillin-resistant-staphylococcus-aureus-pre…
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psnet.ahrq.gov/node/837806/psn-pdf
August 10, 2022 - Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals.
August 10, 2022
Upadhyay S, Opoku-Agyeman W, Choi S, et al. Do patient engagement IT functionalities influence patient
safety outcomes? A study of US hospitals. J Public Health Manag Pract. 2022;28(5):505-512.
doi:…
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psnet.ahrq.gov/node/45464/psn-pdf
September 07, 2016 - Measuring adverse events in hospitalized patients: an
administrative method for measuring harm.
September 7, 2016
Martin J, Benjamin EM, Craver C, et al. Measuring Adverse Events in Hospitalized Patients: An
Administrative Method for Measuring Harm. J Patient Saf. 2016;12(3):125-31.
doi:10.1097/PTS.000000000000007…
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psnet.ahrq.gov/node/72832/psn-pdf
March 10, 2021 - Communication and Transparency as a Means to
Strengthening Workplace Culture During COVID-19.
March 10, 2021
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To
Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021.
doi:10.31478/202103a.
https:/…
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psnet.ahrq.gov/node/60233/psn-pdf
April 15, 2020 - Identifying safety hazards associated with intravenous
vancomycin through the analysis of patient safety event
reports.
April 15, 2020
Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin
through the analysis of patient safety event reports. Patient Safety. 2020;2…
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psnet.ahrq.gov/node/38064/psn-pdf
February 23, 2009 - Same system, different outcomes: comparing the
transitions from two paper-based systems to the same
computerized physician order entry system.
February 23, 2009
Niazkhani Z, van der Sijs H, Pirnejad H, et al. Same system, different outcomes: comparing the transitions
from two paper-based systems to the same comput…
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psnet.ahrq.gov/node/47304/psn-pdf
October 24, 2018 - Mind the overlap: how system problems contribute to
cognitive failure and diagnostic errors.
October 24, 2018
Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure
and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014.
https://psnet.…
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psnet.ahrq.gov/node/39858/psn-pdf
September 22, 2010 - Problems after discharge and understanding of
communication with their primary care physicians (PCPs)
among hospitalized seniors: a mixed methods study.
September 22, 2010
Arora V, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication
with their primary care physicians among h…
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psnet.ahrq.gov/node/848085/psn-pdf
April 26, 2023 - Understanding complexity in a safety critical setting: a
systems approach to medication administration.
April 26, 2023
Stevens EL, Hulme A, Goode N, et al. Understanding complexity in a safety critical setting: a systems
approach to medication administration. Appl Ergon. 2023;110:104000. doi:10.1016/j.apergo.2023.1…
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psnet.ahrq.gov/node/844987/psn-pdf
February 22, 2023 - Examining medication ordering errors using AHRQ
Network of Patient Safety Databases.
February 22, 2023
Grauer A, Rosen A, Applebaum JR, et al. Examining medication ordering errors using AHRQ network of
patient safety databases. J Am Med Inform Assoc. 2023;30(5):838-845. doi:10.1093/jamia/ocad007.
https://psnet.ahr…